Comparison of porcine versus bovine surfactant in preterm respiratory distress syndrome: Evidence from real-world data. A multicentre collaboration from Karnataka.

BACKGROUND & OBJECTIVES: Porcine surfactant (200 mg/kg initial dose) seems to be superior to bovine surfactants (100 mg/kg) in respiratory distress syndrome (RDS). There is limited data on the choice of surfactant from the developing world. Logically, using higher doses of porcine surfactant comes with an additional cost burden. We decided to evaluate the clinical effects of different types of surfactants. METHODS: A retrospective analysis was conducted from August 2019 to December 2022 in six tertiary centers. Neonates 24-34 weeks of gestation with RDS requiring either porcine (200 mg/kg) or bovine surfactant (100 mg/kg) were enrolled. The proportion of BPD, redosing, and other morbidities in either group were analyzed. The outcomes in preterm ≥28 and <28 weeks subgroups were analyzed. RESULTS: Of 1149 eligible babies, 302 (26%) received surfactant after stabilization with CPAP. One hundred fifty-eight received porcine, and 144 received bovine surfactant. There was a higher BPD in porcine compared to the bovine group on univariate analysis [24 (15%) vs. 6 (4%); OR: 4; 95% CI: 1.6-10; p = 0.002]. On logistic regression, the gestational age and PDA requiring treatment were independent predictors of BPD, and the type of surfactant and centres did not influence BPD. Redosing [27 (17%) vs. 18 (12%), OR: 1.4; 95% CI: 0.7-2.7; p = 0.2] was not different between both surfactant types. Other morbidities like mortality, air leaks, invasive ventilation, and CPAP duration were also not different between the groups. CONCLUSION: We could not find a difference in the outcomes of BPD and redosing using porcine surfactant at 200 mg/kg compared to bovine surfactant. Considering the cost burden in the developing world, efficacy needs to be evaluated in randomized clinical trials.

Feeding in Preterm Neonates With Antenatal Doppler Abnormalities: A Systematic Review and Meta-Analysis.

OBJECTIVES: In this systematic review and meta-analysis, we attempted to determine the most appropriate feed initiation and advancement practices in preterm neonates with antenatal Doppler abnormalities. METHODS: We included randomized controlled trials comparing different feed initiation and advancement practices in neonates with antenatal Doppler abnormalities. The databases of PubMed, Embase, Cochrane, CINAHL, Scopus, and Google Scholar were searched on February 25, 2022. The risk of bias was assessed using the Risk of Bias tool, version 2. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. RevMan 5.4 was used for data analysis. RESULTS: Of the 1499 unique records identified, 7 studies were eligible for inclusion (6 on feed initiation, 1 on feed advancement). Early enteral feeding did not increase NEC stage 2 or more [risk ratio (RR) 1.12, 95% confidence interval (CI) 0.71-1.78; 6 studies, 775 participants] and mortality (RR 0.83, 95% CI 0.47-1.48; 5 studies, 642 participants). A trend was noted towards an increase in feeding intolerance (RR 1.23, 95% CI 0.98-1.56; 5 studies, 715 participants). There was a significant reduction in age at full enteral feeds, duration of total parental nutrition, and rates of hospital-acquired infections. Rapid feed advancement decreased the age at full enteral feeds without affecting other outcomes. The overall certainty of the evidence was rated low. Heterogeneity was not significant. CONCLUSION: There is low-certainty evidence that early feed initiation in preterm neonates with antenatal Doppler abnormalities does not increase rates of NEC and mortality. There is insufficient data on the speed of feed advancement.

Prediction score for prolonged hospital stay in meconium aspiration syndrome: A multicentric collaborative cohort of south India.

BACKGROUND AND OBJECTIVE: With improved survival in neonates with meconium aspiration syndrome (MAS), the focus is currently on mitigating the morbidities. The objective of this study was to predict factors determining prolonged hospital stay in neonates with MAS. MATERIALS AND METHODS: It was a retrospective cohort from five centers of south India between 2018 and 2020. Neonates ≥35 weeks of gestation admitted to neonatal intensive care unit with the diagnosis of MAS and requiring oxygen beyond 24 h of life were included in the study. The morbidities in the neonates with stay ≤7 days (short stay) were compared with >7 days (prolonged stay). Logistic regression by the backward stepwise method was used for predictive score creation. RESULTS: Out of 347 neonates with MAS discharged home, 103 (29%) had a short stay and 244 (71%) had prolonged stay. The primary support beyond O2 (continuous positive airway pressure/mechanical ventilation) (42% vs. 83%, p < 0.001), fractional inspired oxygen (FiO2 ) at 1 h >30% (45% vs. 87%, p < 0.001), hypoxic ischemic encephalopathy (HIE) stage 2 or 3 (1% vs. 27%, p < 0.001), moderate-severe persistent pulmonary artery hypertension (PPHN) (3% vs. 31%, p < 0.001) were independent factors associated with prolonged stay on logistic regression. A prediction model was devised using weighted scores of these four associated morbidities. The clinical score thus developed had 83% sensitivity, 68% specificity for the prediction of prolonged stay (area under curve: 82%, 95% confidence interval [78-87], p < 0.001). CONCLUSION: More than two-thirds of neonates with MAS had prolonged stay. The primary support beyond oxygen, FiO2 requirement >30%, Moderate to severe PPHN, HIE stage 2 or 3 were predictive of prolonged stay in neonates with MAS.

Implementing a three-hourly feeding schedule in stable preterm infants to decrease maternal fatigue.

BACKGROUND: A three-hourly feeding schedule has been shown to be as safe as a two-hourly schedule in preterm neonates. It saves nursing time and may be less tiring for the mothers. However, tradition and apprehensions have prevented its wider acceptance. We used a quality improvement approach to implement a three-hourly feeding schedule in stable preterm infants >32 weeks postmenstrual age (PMA) in our unit through a series of plan-do-study-act (PDSA) cycles. METHODS: All preterm neonates >32 weeks PMA, who were on full enteral feeds and without any respiratory support were eligible. The key quantitative outcome was maternal fatigue score. Safety was assessed in terms of episodes of hypoglycaemia and feed intolerance. Qualitative experiences from nursing staff were captured. The volume of expressed breastmilk and requirement of formula feeds were also recorded. After recording baseline data on a two-hourly feeding schedule, four PDSA cycles were sequentially completed over 21 weeks. The results of each PDSA cycle informed the change strategy for the next cycle. RESULTS: In the baseline phase, five neonates on a two-hourly schedule were studied. In PDSA cycles I, II, III and IV, a cumulative of 122 neonates were studied on a three-hourly schedule. There was a significant decrease in median maternal fatigue score (13 (IQR 8-23) to 3 (IQR 1-6); p=0.01)). Only one neonate had feed intolerance, while two had mild asymptomatic transient hypoglycaemia. Six (5%) neonates were shifted to two-hourly feeds temporarily due to transient reasons. Nursing staff felt mothers could devote more time to Kangaroo mother care. The volume of expressed breastmilk and requirement of formula feeds were not different from the three-hourly schedule. CONCLUSIONS: It was possible to change the traditional two-hourly feeding schedule to three-hourly in stable preterm infants using a quality improvement approach, while objectively documenting its safety and benefits.

Low vasopressin and progression of neonatal sepsis to septic shock: a prospective cohort study.

The study objective was to analyze the association between low plasma vasopressin and progression of sepsis to septic shock in neonates < 34 weeks gestation. Septic neonates of < 34 weeks gestation were consecutively enrolled; moribund neonates and those with major malformations were excluded. Subjects were monitored for progression of sepsis to septic shock over the first 7 days from enrolment. Plasma vasopressin levels and inducible nitric oxide synthase levels were measured at the onset of sepsis (T0), severe sepsis (T1), and septic shock (T2). Primary outcome was plasma vasopressin levels at the point of sepsis in those who progressed to septic shock in comparison with matched nested controls in the non-progression group. Forty-nine (47%) enrolled subjects developed severe sepsis or septic shock. Plasma vasopressin levels (pg/ml) at the onset of sepsis were significantly low in those who progressed to septic shock (median (IQR), 31 (2.5-80) versus 100 (12-156); p = 0.02). After adjusting for confounders, vasopressin levels were independently associated with progression to septic shock (adjusted OR (95% CI), 0.97 (0.96, 0.99); p = 0.01).Conclusion: Preterm septic neonates who progressed to septic shock had suppressed vasopressin levels before the onset of shock. Low vasopressin levels were independently associated with progression to septic shock.What is known:• In animal sepsis models and adult septic patients, exuberant production of nitric oxide metabolites and low vasopressin levels have been reportedly associated with progression to septic shock.• Vasopressin levels have been variably reported as low as well as elevated in children with septic shock.What is New:• Preterm neonates who progressed from sepsis to septic shock had significantly lower levels of vasopressin before the onset of shock in comparison with those who did not progress.• Low vasopressin levels independently predicted the progression from sepsis to septic shock in this population.